Provider Demographics
NPI:1972508828
Name:BLOUNT, KELLY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:BLOUNT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5603 DURALEIGH RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-2688
Mailing Address - Country:US
Mailing Address - Phone:919-791-0840
Mailing Address - Fax:919-791-0911
Practice Address - Street 1:5603 DURALEIGH RD
Practice Address - Street 2:SUITE 111
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-2688
Practice Address - Country:US
Practice Address - Phone:919-791-0840
Practice Address - Fax:919-791-0911
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NC103450363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP57322Medicare UPIN
NC2333971Medicare PIN